Flexible fibreoptic colonoscopy is the current gold standard
investigation for diseases of the colon, as it allows direct
visualisation of the entire colon and several therapeutic interventions.
[1-3] However, colonoscopy is technically difficult to master and is
associated with a significant number of complications. There has
therefore been considerable interest in attempts to standardise the
teaching of the procedure and in the accreditation of endoscopists, and
several regulatory bodies and societies have developed norms and quality
markers for endoscopists. [1-3] The advent of dedicated colonoscopic
screening programmes around the world has focused attention on the
sensitivity and specificity of colonoscopy, and the endoscopist must
provide proof of competency based on detailed logbooks. Logbooks are
also required for training purposes. Most examining bodies rely on them
to ensure that candidates sitting board and fellowship examinations have
been exposed to an adequate spectrum of pathology and procedures and
have documented evidence that they are competent in these procedures.
[4,5] Previously, all record-keeping in our institution was paper based,
which made it difficult to record and analyse data, and it was
impossible to monitor quality markers and to benchmark the service. The
development of our electronic medical record systems enabled us to keep
detailed electronic records of all endoscopic procedures. [6,7] By
keeping these data in a relational database, we can perform detailed
audits of colonoscopies at our institution. We aimed to use data from
such an audit to benchmark our results against international quality
guidelines and to provide individual endoscopists with a procedural
logbook.

Setting

Grey's Hospital is a tertiary hospital in Pietermaritzburg,
KwaZuluNatal Province (KZN), South Africa. The city has a population of
just under one million people. Grey's Hospital is the tertiary
referral hospital for the entire western part of KZN, which is a very
rural area with a population of about two million people. The
Gastroenterology Unit at Grey's functions with two colonoscopes,
and is staffed by a core team of dedicated nursing staff. A dedicated
colorectal surgical service at Grey's is staffed by a senior
surgeon, a single subspecialist surgeon (<5 years' clinical
experience) and a single colorectal fellow in training. However, not all
colonoscopies are performed by these three doctors. Since 2013
Grey's Hospital has run a Hybrid Electronic Medical Registry (HEMR)
that captures the admission, operative, endoscopic and discharge data of
all surgical patients in a relational database. [7] This database is
clinician maintained and audited.

Methods

We retrospectively reviewed the prospectively maintained HEMR for
all colonoscopies performed between March 2013 and March 2014. These
data were used to generate a procedural logbook for each endoscopist
and, for competency, were based on the published guidelines [3] of the
American Society of Gastroenterology (ASGE), specifically noting the
following quality markers: (i) number of procedures per individual
endoscopist; (ii) quality of the bowel preparation; (iii) number of
times the caecum was intubated; (iv) number of adenomas detected at each
procedure; (v) complications; and (vi) number of incomplete procedures.

Results

A total of 843 colonoscopies were performed. Fig. 1 documents the
indications for the procedure.

Three colorectal service endoscopists, who each performed more than
the required 150 procedures annually, performed a total of 770
procedures. The remaining 73 (8.7%) were performed by other staff. In
105 cases (12.5%), bowel preparation was deemed to be inadequate, which
caused the procedure to be abandoned in 34 cases. A total of 64 cases
were deemed to be incomplete because of obstructing lesions (n=26),
extensive diverticulosis (n=4), technical difficulty (n=31) and patient
discomfort (n=3). The completion rates of the three members of the
colorectal team are documented in Table 1. Both endoscopists with more
than a year's experience had completion rates approximating 98%.
Table 1 also documents the adenoma detection rate per endoscopist. There
were two complications recorded: perforation (n=1) and rectal bleeding
(n=1). Table 2 lists the complications against level of experience. Fig.
2 summarises the entire cohort.

Discussion

Increased awareness of quality issues in healthcare has resulted in
the development of quality metrics to provide an index against which
clinicians and institutions can measure their performance. Many
international associations for flexible endoscopy have therefore
promulgated quality metrics for various endoscopic procedures. We used
the guidelines of the ASGE, and benchmarked our unit's experience
against these guidelines. Incomplete examinations owing to obstructing
lesions or faecal obstruction are regarded as failed procedures, and
there should be a polyp detection rate of [greater than or equal to]20%.
The data in the HEMR enabled comparison of our experience with those of
published guidelines:

1. Number of procedures. An endoscopist must be affiliated with a
screening centre and must have performed at least 1 000 examinations
over his/ her professional lifetime. There should have been at least 150
examinations performed in the preceding 12 months by each
endoscopist/1-51 Three of the staff performing the procedure worked in
the colorectal service and easily met this requirement, suggesting that
we have an adequate caseload for the training of colorectal specialists.
The remaining procedures were preformed by a variety of endoscopists
from different services.

2. Quality of bowel preparation. The ASGE suggests that the
percentage of outpatient examinations with inadequate bowel preparation
should not exceed 15% of all procedures. The reported incidence of 13%
in this series was within these guidelines. Inadequate bowel preparation
makes the procedure technically more challenging and increases the risk
of an incomplete study and of complications. [1-3,8,9]

3. Rate of complete colonoscopy. For a study to be deemed complete,
the endoscopist must intubate the terminal ileum and visualise the
appendiceal orifice. The rate of complete colonoscopy should be >90%
for diagnostic colonoscopy and >95% for screening colonoscopy; these
rates are being achieved in our endoscopy service. [1-3] Both
endoscopists with more than a year's experience with the procedure
had significantly higher completion rates than the first-year trainee.

4. Detection rate of adenoma. Each endoscopist should identify one
or more adenomatous polyps in at least 25% of men and 15% of women aged
>50 years who are undergoing a screening colonoscopy. Although few of
our procedures were true screening colonoscopies, our detection rate is
in keeping with this. [1-3,10,11]

5. Complications. The rate of perforation secondary to colonoscopy
is currently in the order of one perforation per 1000 -1400
examinations. [1] Table 2 summarises the complications. Our complication
rate is slightly higher than the suggested rate, based on the ASGE
guidelines. Ongoing audit is necessary to determine whether this problem
is persistent and whether a quality improvement programme is necessary
to address this. [1-3,10,12]

The ongoing drive to ensure that training is quantified and
standardised across national centres has involved the mandatory keeping
of procedural logbooks. However, these logbooks have mostly been manual,
and concerns have been raised that they are not standardised. A recent
review of operative logbooks found that the method of logging data is
trainee-dependent and not uniform, making their evaluation extremely
tedious.1451 The development of the HEMR allows individuals to keep an
accurate electronic record of procedures performed, thereby improving
the quality and usability of procedural logbooks. The drive to develop
subspecialist training programmes in surgical gastroenterology is
ongoing. An adequate caseload for training is vital to ensure that these
training programmes are credible and produce appropriately trained
subspecialists. Our caseload seems to be appropriate for both
subspecialist trainees. The three staff members from the colorectal
service each met this requirement, suggesting that our caseload is
adequate for the training of colorectal specialists. The development of
this HEMR system enabled our service to quantify our workload accurately
and to benchmark our service against international guidelines. We could
also establish a workload that can be used to support training
initiatives. This has implications for service delivery and educational
purposes.

References

[1.] Chen SC, Rex DK. The endoscopist can be more powerful than age
and male gender in predicting adenoma detection at colonoscopy. Am J
Gastroenterol 2007;102(4):856-861.
[http://dx.doi.org/10.1111/j.1572-0241.2006.01054.x]

[3.] American Society for Gastrointestinal Endoscopy and American
College of Gastroenterology. http://www.asge.org/
uploadedFiles/Publications_(public)/Practice_guidelines/2014_
Quality_in_endoscopy_set.pdf (accessed 10 October 2015).

[4.] Colleges of Medicine of South Africa. Fellowship of the
College of Surgeons of South Africa: FCS (SA), 2013. http://www.
collegemedsa.ac.za/view_exam.aspx?examid=46 (accessed 3 December 2013).

Gastroenterology Unit, Grey's Hospital, Pietermaritzburg, and
Department of Surgery, School of Clinical Medicine, College of Health
Sciences, Nelson R Mandela School of Medicine, University of
KwaZulu-Natal, Durban, South Africa